AWHONN Study Urges U.S. Hospitals Not To Guestimate Blood Loss, Weigh Bleeding Pads

According to an 18-month study from the Association of Women’s Health, Obstetric and Neonatal Nurses, postpartum hemorrhage, or PPH, is one of the biggest reasons serious complications and death can occur in the delivery room.

This leads to the question of how much blood loss is acceptable during childbirth.


Researchers looked at 95 hospitals in both George and New Jersey, where there’s a high maternal mortality rate. According to the authors, maternal deaths as the result of postpartum hemorrhage were between 54 and 93 percent, and could have been prevented.

The AWHONN study noted and calculates some observations doctors and nurses have been making since the 1960s regarding the inaccuracy of visual estimate in the amount of blood loss.

According to Renee Byfield, an AWHONN nurse program development specialist and a study author, said for years, the medical community has been way off the mark. And, by how much is troubling, since blood is necessary for saving a life.


Byfield has more than 20 years’ experience in the high-risk obstetrical nursing field. According to her, it’s normal to just estimate the blood loss after a baby has been born by looking at the absorbent pads under the patient’s body. A visual estimation leads doctors and nurses to determine if the blood loss is large, moderate or small.

Of course, what’s large, she said. One doctor’s large may be someone else’s moderate and so on. Byfield said it’s all just guessing.

500 millimeters of blood loss is the average amount during a vaginal birth. 1,000 millimeters can be lost during a C-section. Anything above this is thought to be dangerous.


According to Byfield, PPH treatment is determined on how much blood was lost, which is why there need to be standards for teams to properly respond. And, it means weighing the pads to determine how much blood loss has occurred.

Lashea Wattie, clinical nurse specialist for Wellstar Kennestone Hospital in Georgia, said it’s almost always too late to do something when doctors realize how much blood has been lost. Using a quantified blood loss means being able to determine what stage the patient is in and how critical she is.

The study revealed the problem with racial disparity, noting that four million women give birth every year, with 125,000 of them suffering from postpartum hemorrhage. Of that amount, black women have a higher maternal mortality rate than white women (68.3 per 100,000 compared to 21.0 per 100,000).

Byfield said researchers are still looking at the information, but that there is a 4 to 1 ratio where African American women have more PPH than other races do. It’s not about economics, but access to care since community hospitals don’t have the ability to handle the problem effectively. Hospitals that really need the understanding of PPH have no tools or training to combat the problem.


American Congress of Obstetricians and Gynecologists said PPH doesn’t just impact black women disproportionately. African American women have a four times higher rate of dying from birth compared to other women of other races.

When it comes to maternal mortality, the U.S. ranks 33rd in the world out of 179 countries that took place in the Save the Children 16th State of the World’s Mother Report taken in 2015. Georgia is thought to be attributed to the problem. Although strides have been made, there are just 79 out of 159 counties that have an OB-GYN.

Wattie said additional training is necessary for various places. Smaller hospital staff don’t have labor and delivery rooms, but can deliver babies when necessary. The same goes for rural area emergency medical technicians.  Wattie said smaller hospitals could deal with normal deliveries but due to the increased risks, they need to consider undergoing a postpartum hemorrhage preparedness course.


Of course, these drills means the hospital staff needs to make a commitment to the time it’ll take – time that’ll be well-spent.  Still, they can go back over and over the training, and do a valuable debriefing after each delivery, complicated or routine.

Wattie said it’s imperative that doctors and nurses are proactive before a woman in labor comes into their hospital, and it’s too late to handle the situation, and she needs a blood transfusion.